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    Unemployment Effects on Health Flowchart

    How does unemployment affect health?

    Thanks to  Julian Beeton of Lewisham Healthcare NHS Trust for the design and  Meic Goodyear Public Health Lewisham for the content. Reproduced by permission

    Job insecurity contributes to poor health

    Job insecurity was associated with significant increases in self reported poor health, depression, and anxiety. Paid work confers health benefits, but poor quality jobs which combine several psychosocial stressors could be as bad for health as being unemployed.

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    Life expectancy and poverty in London

    WHAT THE MAP PLOTS

    • The life expectancy at birth of those living within a 200m radius of each London Underground, London Overground and Docklands Light Railway (DLR) station
    • The rank of each London ward on the spectrum of Income Deprivation Affecting Children Index

    The full map

    Tagged | Comments Off on Life Expectancy at birth in London
    • Julia Burrows
    • Susan Baxter
    • Wendy Baird
    • Julie Hirst
    • Elizabeth Goyder

    School of Health and Related Research, Regent Court, Regent Road, Sheffield S1 4DA

    Corresponding author:

    Julia Burrows Email: j.burrows@sheffield.ac.uk Telephone:  0114 2221722

    Abstract

    Background

    The potential to improve health by reducing poverty, debt and other social problems has been suggested. Research indicates that the provision of welfare advice in general practice can secure additional income for patients and help manage debt.

    Aim

    To examine the views of primary care staff and users of advice services located in general practices, and to identify key factors perceived as contributing to the intervention’s success or difficulties.

    Design of Study

    A qualitative interview study

    Setting

    Two General Practices (one urban and one rural) in the UK

    Methods

    Semi-structured interviews (n=22) with five primary care and practice staff, five CAB advisors and twelve service users.

    Results

    Key positive service features were seen by all groups as the confidential and familiar GP surgery environment; ability to make appointments; experienced advisor availability and continuity.  Outcomes for service users were described as financial gain and managed debt, along with beneficial social and mental health impacts.  Staff benefits were perceived to be appropriate referral, and better use of GP consultation time.

    Conclusion

    Welfare advice in primary care provides financial benefit and was perceived by participants to offer health and other benefits to patients and staff.  However, while perceptions of gain from the intervention were evident, demonstration of measurable health improvement and wellbeing presents challenges.  Further empirical work is needed in order to explore these complex cause-effect links and the cost-effectiveness of the intervention.

    How this fits in

    Welfare advice in primary care is known to be an effective way to help patients to secure financial benefits and manage debt and some (uncontrolled) studies suggest health gains.  This study reports the views of clinicians, advisors and service users of a service delivery model used across rural and urban settings.  The study is particularly relevant at a time when clinicians are likely to be increasingly dealing with patients in financial hardship. With the anticipated changes in UK commissioning arrangements, GP consortia will need appropriate evidence to support their commissioning decisions, and this will include the decision about whether or not to invest in welfare advice services in primary care.

    Keywords

    Citizens advice; welfare advice; welfare benefits; primary care; general practice; poverty.

    Introduction

    Welfare advice in primary care has been suggested as a promising approach to tackling poverty as a determinant of ill-health1 23. Previous studies have demonstrated positive outcomes for patients including financial gain4 and improvements in measures of mental health and wellbeing56. Although there is a strong theoretical argument for improving health by tackling financial hardship3, evidence of health gain from welfare advice in health settings has been elusive78. To date, the provision of advice in primary care has tended to be implemented as scattered projects throughout the United Kingdom (UK)3.

    The locality examined in this study has pioneered welfare advice as a key strategy to tackle health inequality for over ten years. Citizens Advice Bureaux (CAB) are charitable organisations, staffed by paid employees and volunteers, with offices in most towns throughout the UK.  CAB were chosen for this initiative as they provide free, independent and confidential advice related to any issue9, rather than specific benefits advice or debt counselling services that have been explored in other studies10-12.

    During the period under investigation, 50% of the locality’s general practices offered an in-house CAB service to their patients.  A trained CAB advisor was available at each practice for one half-day each week. The CAB advisor had access to a telephone and computer.  The advisor spent a further half-day at bureau headquarters doing follow-up work, such as writing to creditors and attending tribunals.  The service was open access, with self-referral and referral from primary health care team members.  Appointments of 45 minutes duration were made with the practice receptionist.  The service cost £8850 per practice/year and was funded by the Primary Care Trust (PCT) as a public health intervention.

    Data collected for the 2009-10 period indicate that 3,490 clients were seen.  Of these, one in four (27%) received additional income as a result of that advice. Additional income totalling £4,545,623 was secured for clients and £7,660,593 of debt was managed.  For every £1 invested in the project it secured £6.97 in additional income for its users and managed £11.75 of their debts.    This study sought to gain understanding of this welfare advice provision beyond the financial outcomes.  It sought to explore perceptions of service delivery, including identified benefits to patients and staff.

    Methods

    Selection and recruitment of participants

    We invited a range of stakeholders to participate, including patients, CAB advisors, primary care clinicians, practice managers and commissioners from two practices, one rural and one urban, that had hosted the service for over five years.  Professionals were invited by letter. In order that anonymity was not breached, users were identified via the CAB service by purposive selection of a sample of users to achieve a range of gender and age.  Letters of invitation with information sheets and postage-paid envelope and reply slip were sent by the CAB service to 90 users. A poor response rate led to a change in strategy, with advisors handing out the packs. A further 40 invitations to participate were distributed via this method.

    Interviews

    Interviews took place in early 2010 and lasted 30-50 minutes. Topic guides were devised following a review of the literature and consultation with key stakeholders.  Three topic guides were developed: one for users; one for primary care staff and one for CAB advisors. Interviews were carried out by two members of the research team who are experienced qualitative researchers. Interviews with staff took place in their office or practice.  Service user interviews took place at their home or in their GP surgery according to their preference.

    Analysis

    Interviews were tape-recorded with consent and transcribed verbatim. The transcripts were read on a line-by-line basis with codes assigned to perceptions or ideas. Data within and between codes were retrieved for comparison and consistency checking in an iterative process to develop key recurring themes13 supported by the NVivo 814 software.  The initial analysis was undertaken by the second author, with subsequent discussion with the first author of code structure as findings emerged.  The stage at which data saturation occurred was agreed between these two members of the research team.

    Findings

    Sample

    We interviewed ten staff and twelve service users. Tables I and II describe participant characteristics.  The staff group included five CAB advisors, one GP, one Health Visitor, one PCT commissioner and two practice managers.  All had five or more years’ experience of working with CAB in primary care.

    The response rate for CAB advisors was 100% and 50% for practice staff.  Three service users replied from the initial mailing (of 40) and four from the second mailing (of 50). Three further responses were obtained from advisors handing out the information. Two couples responded, both agreeing to be interviewed, giving the final sample of twelve service users.  Data analysis occurred in parallel with data collection, with no new themes emerging by the 11th and 12th user interviews. The researchers considered that at this point saturation15 had been reached, therefore further recruitment attempts ceased.

    Analysis of the data highlighted a number of themes relating to process and outcomes for users and staff (see Figure 1).

    1. Process

    Referral

    An important means of accessing the service was by referral or suggestion from a staff member at the health centre/surgery.

    So the doctor recommended, you know, go and see citizens advice so I did (User 7)

    So a lot of the referrals come from the docs, the docs saying that it would be a good idea if you had a word with CAB (Advisor 2)

    (A) good number are self-referrals, but all the health professionals here are aware of the CAB and will refer them to them if necessary (Staff 5)

    There was the suggestion that the recommendation coming from a doctor could make a difference as to whether the service was accessed.

    A lot of people see the posters at GP surgeries but often its the GP who says specifically you need to go and get help with this (Advisor 1)

    While referrals (particularly from GPs) were reported to be important in users accessing the service, there was some suggestion in the data that the potential for referral was not always fully realised.

    He didnt mention that they were there to me, but I never mentioned that I had money problems to him anyway. But maybe just making people more aware there is a worker there to help (User 10)

    Some participants suggested that rather than relying on individual professionals to instigate referral, a more proactive system could be beneficial, such as a trigger system or automatic referral in response to particular life events.

    One year I was able to add a little paragraph to their flu shot letter saying you know if youre over 60 please come in for a benefits check just to see that youre getting everything that youre entitled to and we got a really good response to that (Advisor 4)

    Word of mouth

    Another important source of access to the service was reported to be via ‘word of mouth’ locally.  There were examples in the data of service users telling friends and relatives about the service or having heard about it from these sources rather than from professionals.

    Now the word has spread and a lot of people are accessing the service directly as well, theyve heard from a neighbour or a friend or what have you (Staff 3)

    Speed of access

    Staff reported that the GP-based service offered a choice for users in which service they could access.  There was a perception that the outreach service could offer earlier or speedier access to help which was beneficial in terms of resolving problems at an early stage.

    We can nip things in the bud much earlier and allow people to kind of start to resolve things much more easily I think by having a local service (Advisor 1)

    However, this perception was not described by all, with some reports that it took longer to access a GP surgery appointment than the town centre ‘drop-in’ service.

    Thats the only problem.  I think we had to wait sort of two weeks was it? (User 2)

    A drop-in system, while potentially offering the opportunity for an early appointment was not always viewed as easier to access however.

    So you pass it many times, but its closed. (Staff 5)

    Drop in versus timed appointment

    Generally the preference amongst users seemed to be for a timed appointment rather than drop-in, a perception that was shared by staff.

    If you go to the doctors and you know theres a Citizens Advice Bureau worker there, then you can just ask to make an appointment (User 10)

    I think people get a better deal if they come to an appointment and they get 45 minutes guaranteed time (Advisor 1)

    In addition to the ‘appointment versus drop-in difference’, GP-based services were also reported to offer a range of options for receiving input.

    Citizens Advice will visit people in their own homes if they can’t get down to the practice (Staff 4)

    Ease of travelling

    A key advantage highlighted was the ease of travelling to a local surgery, particularly for a rural area with poor public transport.

    I think they would be less likely to go to the drop in because theyd have to travel (Advisor 4)

    If we didnt get the CAB which was local then we couldnt get the time to go here (User 3)

    Confidentiality and anonymity

    The most commonly described advantage of the service was that it offered greater confidentiality and anonymity, thus overcoming the perceived stigma associated with seeking help.   Although the service offered advice on a wide variety of issues there seemed to be a perception of a CAB service user as being someone in financial hardship. Users perceived that attending a service in a general practice obscured the reason for their visit and did not publicly declare that they were a service user.

    I would have thought twice if it was on the main road where you can be spotted walking in (User 2)

    I suppose the main one is confidentiality because everybody is at the doctors for something and they dont know who youre going to see. (User 5)

    (Y)ou go in the doctors and nobody sort of takes much notice, do they? Whereas if you were walking into a Citizens Advice Bureau right in Main Street, thats what you are going for, isnt it?  (User 12)

    Continuity

    Another key difference was the continuity or personalised service that was offered.

    People find its more personalised in a GP surgery.  I tend to find that people like coming back to the same person because they dont have to start telling the story all over again (Advisor 3)

    Somewhere people know

    After confidentiality and anonymity, the second most frequently occurring theme related to the importance of services being somewhere that people know.

    I feel safer in an environment because I know shes in the doctors.  I know thats a bit daft (User 10)

     People who don’t really know what’s out in the community to help them, but they always know the doctor (Staff 4)

    I would have gone because the doctor suggested it or it was part of the National Health Service rather than an independent body. I know [its] independent from the doctors surgery but it doesnt feel like that.  It feels like its part of the doctors (User 12)

    2. Outcomes

    Outcomes for service users

    Financial benefits

    The service was reported to have achieved financial gains for users not only through increased or additional benefits, but also by resolving consumer problems and giving debt advice.

    Thats £200 back in the kitty that we can start paying some of the debts off (User 3)

    In addition to financial benefits participants described the impact that input could have in terms of relationship and social gains and improvements to daily living.

    At least we [husband and wife] can talk about these things now (User 2)

    I suppose better quality of care, better eating, better food and being able to provide the necessary equipment (Staff 2)

    They can pay for some extra help coming in that can take quite a burden off for carers so you might be improving the health outcome for the actual individual, the patient, but also their wider family or caring network as well (Staff 3)

    Mental wellbeing gains

    Many of the users talked about the benefits to their mental health which they attributed not only to the practical outcome of the advice, but also to the support they received from the advisors. 

    I mean Im sleeping too.  We are not having stuff like these like little panic attacks.  (User 2)

    [CAB] was invaluable.Id have killed somebody, or killed myself if I hadnt got it sorted out because it was just going downhill (User 12)

    It [CAB] does ease my worries, thats the main thing.  Ive got depression anywayits just knowing that theres somebody there to talk to (User10)

    Several of the service users reported how experiences with government agencies had led to feelings of frustration, lack of self worth and powerlessness when coming into conflict with these large bureaucracies.

     It makes me feel that nobody cares the total mess that they [Job Centre Plus] are in, I was given all sorts of conflicting advice Ive never dealt with such an inefficient organisationIt takes you at least half an hour to get through to them. 

    Its very depressing to be spoke to the way they [Job Centre Plus] speak to you and it definitely puts barriers up to trying to apply and wade through all the mountains that they want and hoops to jump through. (User 5)

    Outcomes for staff

    A resource

    Staff described the CAB service as supporting their own work, a resource and a somewhere to refer to.

    A valuable resource for our clinicians to refer them to (Staff 1)

    A good tool to help me do my job (Staff 2)

    There was discussion of the different roles that CAB and health professionals fulfilled, with perceptions of different or complementary functions.

    GPs cant sort out the practicalities and we can (Advisor 1)

    So the doctor is dealing with one aspect of mental health and we help with the other bits (Advisor 4)

    Time-saving

    The benefit mentioned most frequently was that it was time-saving for doctors.

    Before I’ve actually had to fill the forms in with the parents, or help them and it can take hours (Staff 2)

    The GP probably did spend some time with that patient but probably would have spent a lot more if CAB hadn’t been in their practice (Staff 4)

    I just think its a good idea to keep the doctors surgeries flowing (User 4)

    While being perceived as saving time during consultations, the link between having a CAB service and less contact with a doctor however was not supported by all participants.  Some users saw the service as “an extra” rather than instead of consulting their GP.

    Ive actually made appointments to go and see my doctor, because Im there (User 10)

    I cant think of anyone whos come to me instead of going to the GP as yet (Advisor 3)

    However, some users identified that, without the CAB service, they may have continued seeing the doctor when in fact they needed a different type of help.

    He knew he needed to get me somewhere else.  So [without CAB] he was going to be seeing me week after and week after and I was slowly going to just deteriorate   (User 12)

    Discussion

    Summary of main findings

    The study examined perceptions of staff and service users to identify process and outcome factors associated with a welfare advice service in primary care. The familiar and confidential environment of a GP surgery, the ability to make appointments and the continuity of advisor were seen as key positive aspects of this service.  There were also perceptions of financial gain, together with a positive impact on daily living, social relationships and mental health. The main benefits for staff were reportedly: a resource to refer to; and the potential for saving GP time.

    A key benefit for service users related to avoiding the stigma16 perceived to be associated with accessing welfare advice services.  The reluctance to be publicly identified as needing this type of help was a strong feature of the data.  This perceived stigma has been described in previous studies17 18. The perception of needing welfare advice as an undesirable characteristic is potentially a key barrier to vulnerable people accessing help. This seems worthy of further study.

    Other work has suggested that users of welfare advice services in primary care may differ from services sited elsewhere, such as having more complex problems19or being older5.   While advisors in this study reported no particular trends in demographics, some suggested a much broader range of issues being covered in their primary care caseload, such as consumer and legal advice, contrasting with the almost exclusively ‘debt and benefit’ problems they dealt with in mainstream advice services.  The positive aspects regarding access and delivery potentially could widen the service user population.  This would be important to explore in further work, particularly in regard to reaching those most in need.

    Comparisons with existing literature

    Poverty is a significant driver of health inequalities, with the potential for interventions tackling the financial hardship of patients theoretically to improve health3.  Previous studies have provided evidence of financial benefit for patients through the provision of welfare advice in primary care, with some (mainly uncontrolled) studies indicating the potential for health gains4.   It has been suggested that provision of welfare advice, particularly to older people, is an effective intervention to identify people who are eligible for benefits but are unlikely to have claimed them20.

    This study was designed as preliminary work to gain further insights into the use and potential benefits of the service, with a view to carrying out a larger quantitative evaluation21.  It provides data regarding aspects that enable access and optimise delivery. The study confirms previous work reporting financial benefit and suggests how financial benefits may have a wider positive impact, for example on mental health and social relationships.  It found the perception that CAB in primary care can result in more appropriate use of health services, for example by providing an alternative route of referral for health professionals, and by supporting individuals in addressing the cause of health issues resulting from financial hardship.

    This study contributes to the knowledge base from qualitative and quantitative research in suggesting that there may be a wide range of potential impacts, some more easily measured than others. For most of the potential benefits there is a plausible causal pathway between advice, change in an individual’s circumstances and health benefits, even where these impacts are difficult to quantify.  A promising future approach to studying this area may be to use the existing quantitative and qualitative evidence-base to develop a logic model of the pathways between intervention and outcomes which could be used to inform commissioning decisions22.

    Strengths and limitations of the study

    The study is timely given the current economic situation and increasingly difficult financial circumstances some patients are likely to experience with the potential for a negative impact on their health.  The study explored a range of views from service users and staff working in primary care, both those directly providing the service and those commissioning it or referring patients to it.  The findings enhance the current evidence of financial benefits resulting from investment in the initiative.

    The UK seems to be one of only a small number of countries (including Israel and Ireland) offering local in-person consultations on health and welfare matters. Other countries offer predominantly website and telephone hotline services, for example the Federal Citizen Information Center and Medicare Rights Center (USA), and Community Legal Centres in Australia which offer casework assistance generally by telephone. Socioeconomic determination of health, both at an individual and population level, is a firmly established global phenomenon.  The placing of advice services in  a healthcare setting may give important acknowledgement of this link.

    The sample of participants recruited for this study could be considered unrepresentative of service users since those who had positive experiences of the service may have been more likely to respond as a way of “giving something back” for a service they appreciated.   A reluctance to be identified as someone who needed outside help or who was in financial hardship may have precluded participation for some23. The study highlights the difficulty in recruiting research participants; particularly in an area where there may be embarrassment about using the service under scrutiny, and the preservation of user anonymity precludes direct contact by researchers. Future studies could consider including an invitation from the GP in the pack, or offering a financial incentive, such as a shopping voucher, to take part.

    A range of primary care staff were interviewed from two practices in different settings (rural and urban). Both practices had substantial experience of hosting the CAB service.  However, other than practice managers, only one staff member from each professional group was interviewed.  This small sample offers the possibility that staff who agreed to be interviewed had different views from those of their colleagues.

    Implications for future research or clinical practice

    Key service features perceived to be beneficial have been identified. These elements are important to consider when planning any similar service initiatives.  Welfare advice sessions in general practice can give financial benefit to patients and is perceived by staff and service users to offer health, social and other benefits.  Further empirical work is needed in order to explore these complex cause-effect links.

    Funding

    This work was supported by NHS Derbyshire County.

    Ethics

    Ethical approval was received from the Derbyshire NHS Research Ethics Committee.  REC 09/H0401/56  The change in recruitment procedure was approved as an amendment.

    Competing interests

    One of the authors (JH) is employed by the funding body and has been actively involved in the project, including participating in the study.

    Acknowledgements

    Grateful thanks are due to all the service users and staff who took part and to the Citizens Advice Bureaux and Primary Care Trust for support in undertaking the research, including participating on the steering group and in recruiting participants

    Reference List

    (1)   Jarman B. Giving advice about welfare benefits in general practice. BMJ 1985; 290(6467):519-51a.

    (2)   Paris JA, Player D. Citizens’ advice in general practice. BMJ 1993; 306(6891):1518-1520.

    (3)   Marmot M. Fair Society, Healthy Lives: The Marmot Review. London: University College; 2010.

    (4)   Adams J, White M, Moffatt S, Howel D, Mackintosh J. A systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings. BMC Public Health 2006; 6(81):doi:10.1186/1471-2458-6-81.

    (5)   Abbott S, Hobby L. Welfare benefits advice in primary care: evidence of improvements in health. Public Health 2000; 114(5):324-327.

    (6)   Abbott S. Prescribing welfare benefits advice in primary care: is it a health intervention, and if so, what sort? J Public Health 2002; 24(4):307-312.

    (7)   Thomson H, Hoskins R, Petticrew M, Ogilvie D, Craig N, Quinn T et al. Evaluating the health effects of social interventions. BMJ 2004; 328(7434):282-285.

    (8)   Cousens S, Hargreaves J, Bonell C, Armstrong B, Thomas J, Kirkwood B et al. Alternatives to randomisation in the evaluation of public-health interventions: statistical analysis and causal inference. Journal of Epidemiology and Community Health 2009.

    (9)   Citizens Advice Bureau. http://www.citizensadvice.org.uk   Accessed 1/11/10. 2010.

    (10)   Hoskins R, Tobin J, McMaster K, Quinn T. Roll-out of a nurse-led welfare benefits screening service throughout the largest Local Health Care Co-operative in Glasgow: An evaluation study. Public Health 2005; 119(10):853-861.

    (11)   Hoskins RAJ, Smith LN. Nurse-led welfare benefits screening in a General Practice located in a deprived area. Public Health 2002; 116(4):214-220.

    (12)   Abbott S, Hobby L, Cotter S. What is the impact on individual health of services in general practice settings which offer welfare benefits advice? Health and Social Care in the Community 2005; 14(1):1-8.

    (13)   Mason J. Qualitative Research. Second Edition ed. London: Sage; 2002.

    (14)   QSR International Limited (UK). NVivo 8. Southport: 2008.

    (15)   Strauss A, Corbin J. Basics of Qualitative Research. Second Edition ed. Thousands Oak, California: Sage; 1998.

    (16)   Goffman E. Stigma: Notes on the Management of Spoiled Identity.  Englewood Cliffs, NJ: Prentice-Hall; 1963.

    (17)   Powell JE, Langley C, Kirwan J, Gubbay D, Memel D, Pollock J et al. Welfare rights services for people disabled with arthritis integrated in primary care and hospital settings: set-up costs and monetary benefits. Rheumatology 2004; 43(9):1167-1172.

    (18)   Galvin K., Sharples A., Jackson D. Citizens Advice Bureaux in general practice: an illuminative evaluation. Health and Social Care in the Community 2000; 8(4):277-282.

    (19)   Middleton J, Spearey H, Maunder B, Vanes J, Little J, Norman A et al. Citizens’ advice in general practice. BMJ 1993; 307:504.

    (20)   Mackintosh J, White M, Howel D, Chadwick T, Moffat S, Deverill M et al. Randomised controlled trial of welfare rights accessed via primary health care: pilot study. BMC Public Health 2006; 6(162):doi:10.1186/1471-2458-6-162.

    (21)   Medical Research Council. Developing and Evaluating Comples Evaluations: new guidance. London: MRC; 2008.

    (22)   Baxter S, Killoran A, Kelly M, Goyder E. Synthesising diverse evidence: The use of primary qualitative data analysis methods and logic models in public health reviews. Public Health 2010; 124:99-106.

    (23)   Williams T. Review of Research into the Impact of Debt Advice. The Legal Services Research Centre; 2004.

     

    Comments Off on Welfare advice in primary care: A qualitative study of service user and staff perceptions

    Summary

    The welfare reform agenda in 2011-2017 from government will combine with unexpectedly austere economic conditions and associated cuts to the voluntary sector and legal aid. Over 100,000 existingWolverhamptonwelfare claims will be converted to a new super-benefit, many existing payment levels being reduced, and all capped at £500 per household per week.

    A total sum of between £70million and £120million per year, every year, will be lost from the city economy by 2017. Large family households, headed by a lone parent, will face considerable pressures. The effects will be economically felt much wider than just the claimants’ households.

    Recommendations – summarised

    There are 12 itemised recommendations at the end of this paper. Principal themes amongst them are:

    • The need to see the welfare reform programme alongside other relevant economic factors, such as future financial fragility in the mortgaged sector
    • Creation of a working forecast of all the forthcoming factors, a “Wolverhamptonway”, which can better inform different agencies in planning for and reacting to events, and creating new mitigation plans
    • Identifying particularly vulnerable groups, such as workless lone parents with a large family in a heavily mortgaged property
    • Asking the private sector firms delivering the prevention agenda contracts to join in partnership work
    • Identifying which voluntary sector resources need defending
    • Obtaining research from theUSAexperience since 1996 on (perhaps unfamiliar) issues such as behaviour change and mental wellbeing

    1.0 Background

    Government is committed to transformative welfare reform, to change behaviour and deduct £18 billion from the cost within 4 years. A quarter ofUK public spending (13% of GDP) is today on welfare, although 40% relates to pensioners who have been comparatively protected. There is widespread public support and largely cross-party agreement. The familiar if complex benefits system redesigned by Norman Fowler in the mid 1980s, and variously adjusted by Labour administrations, will be transformed around these driving themes:

    • stronger work incentives (to make work pay and redefine claiming welfare as a temporary status)
    • responsible life choices (especially the size of family when claiming)
    • support for pensioners and those “genuinely” incapable of work, but less so for many other groups

    New legislation has survived a contentious parliamentary passage and will soon replace a plethora of current mainstream benefits (such as Housing Benefit) with one simplified “super benefit” (Universal Credit, UC) starting in October 2013, for claimants who are in or out of work, or moving between. The benefits being abolished are currently supplied by Local Authorities and civil service agencies. This scale of change is ambitious under any circumstances, but set against a double dip recession, high unemployment, a weakened voluntary sector and lowered future growth forecasts, it is an unprecedented programme. InWolverhamptonchild poverty has risen from 17.9% in 2004 to 33.4% in 2011. In the USA, somewhat similar policy changes, starting in 1996, have cut welfare claims by 58%, but in doing so created sub cultures of people who simply fell out of the system, including a category described as “floundering mothers” who cannot keep in work but are simultaneously debarred from claiming state aid, resulting in controversial policy debates about the many children affected by such complex household consequences.

    2.0 Current Position

    a)    Welfare change issues only

    [Indicative figures in this report will be rechecked in forthcoming weeks]. In Wolverhampton there are well over 100,000 live claims to be changed into UC over a 4 year period: Housing Benefit (25,869), Income based JSA (12,108) other out of work benefits (29,700), plus Working Tax Credit and Child Tax Credit are received by 65% of Wolverhampton’s families. Each year even more customers start and stop claims. UC will be applied for by digital default (online) and paid one month in arrears to a bank account. It will be administered by a remote national agency rather than local offices. Direct payments to landlords will cease, meaning the concept of an “earned monthly wage”, with all the responsibilities for the household, is created. In a recent DWP guide it was stated that, until they get a job, a claimant’s job is to get a job.

    Because of the scale of the changes there will be 4 years where de facto 3 different welfare benefits systems co-exist: those already on UC, those still on the legacy benefits package, and those waves of claimants in transition. Alongside this is a parallel change from Disability Living Allowance (DLA) into the newly stringent Personal Independence Payment. This will require a fresh claim for all of the existing 15,700 disabled DLA claimants inWolverhampton. Cuts were made to Housing Benefit in 2011, and more are now occurring. There is also a new Benefit Cap of £500 per week per household.

    The Stoke on Trent municipal information team are suggesting a loss to that city of £106.4million a year, every year. A simplistic per capita assumption aboutWolverhampton’s population compared to the national cuts sum produces a not dissimilar range.

    What are the wider consequences of these changes? Housing Benefit (HB) is in reality a rent subsidy which funds landlords. InWolverhamptonthe housing supply is 7% private sector landlords and 25% the ALMO. Rent arrears are expected to grow as some claimants cannot or will not make up the shortfalls caused by HB reductions. The amount of housing related enquiries coming to the CAB inWolverhamptonhas already increased from 7% in 2008 to 18% in 2011.

    The Benefit Cap is a novel fixed ceiling on all household welfare income, irrespective of family size. Early government estimates predict circa 70,000 households will be affected at an average loss of £83 weekly from April 2013. 56% are in the private rented sector, 69% have more than 3 children and 52% are lone parents. The Black Countryhas an unexpectedly high volume of such households and preliminary letters are already going to them. £83/week is £4312 a year. DWP staff work to “vulnerability” triggers but need claimants to engage, and are not knowledgeable about housing stock quality or local rent issues. Initial claimant responses are apparently defeatist. If 500 families lose the average modelled sum, this equates to just over £2million in Wolverhampton.

    b)   Economic background issues

    A fair wind does not exist for welfare reform:

    • youth unemployment is high and inadequate numbers of good jobs exist to move claimants into
    • flat wages are being eroded because of rising costs of living
    • fuel and food inflation is especially high
    • increasingly bold marketing of “pay day loans” at extortionate interest rates (4000% APR from one popular mainstream company) are flourishing, and local CAB evidence suggests a growing negative trend
    • Enquiries at Wolverhampton CAB for “threatened homelessness” have continued to rise year on year since 2008: 141, 286, 625, 743, and these are before the welfare cuts have really started

    Other more currently favourable phenomena will drop away:

    • there is a small temporary effect of PPI claims (for mis-sold payment protection insurance) coming back to local people, possibly £2million pa
    • the standard variable rate of mortgages has been held low for 3 years, offering up to £300 a month interest relief on an average priced Wolverhampton fully mortgaged property of c£126,000 – this could end in 2013/14, and if only 10,000 properties were affected this would still drain £36million pa from the city. 60% of local property is owner occupied
    • cuts of freely available discrimination casework in 2012 and to legal aid in January 2013 will remove all publicly funded assistance to low income households in the subjects of discrimination, employment and welfare benefits law, and most debt advice too; the cuts have been opposed because £1 spent on legal aid is reliably estimated to save at least £4 to the tax payer. This means 1,400 fewer cases to be run inWolverhampton(and 12 key jobs lost at the CAB), or about £1.2million more cost to the local public purse.

    And a particular concern lurks concerning owner occupied housing stock in future and the number of children in households accepted as homeless:

    • it is widely forecast that a rush of mortgage repossessions will occur at the end of the downturn, as the national economy and housing market recovers, and interest rates rise, but unemployment lingers locally. Repossession figures for Wolverhampton postcodes to date for 2007 to 2010 inclusive are 535, 655, 320 and 285. This shows how effective the post credit crunch support responses have been locally (the MRS, CAB and City Council activity), plus mortgage lenders not viewing repossession as attractive in a depressed market, and the protective effect of the low Bank of England led SVR. In 2012 the CAB continues to advise over 500 households annually with serious mortgage debt, and reschedules most onto the low SVR. Once that SVR changes, all of these recently stabilised cases unravel afresh, and simultaneously
    • recent figures from Housing Options inWolverhamptonshow that of 175 families accepted as homeless last year, 473 children were involved

    c)    Prevention services

    One of the hopes of the government agenda is a real appetite for prevention work, and the use of bank levy money (“polluter pays”) to fund a national debt advice scheme (rather than tax payer income) is a long overdue reform. The heavily funded Work Programme and Troubled Families schemes also seek to combine to reduce obstacles to job hunters or families on welfare and the new Money Advice Service offers basic guidance on financial planning and awareness.

    As things stand these new nationally tendered contracts have all been won forWolverhamptonby private contractors such as EOS, Pertemps, In Training and A4e. Despite early meetings these firms are not currently participating in the established partnership frameworks, for reasons which are as yet unclear.

    d)   Big Society

    Another government ambition was to stimulate more local and informal sources of micro help and mutual support for those in communities. Unfortunately, due largely to other central government cuts, all of the recognised voluntary agencies in Wolverhampton able to help with the welfare agenda are today in far worse fettle than they were in 2010. The CAB has lost 24% of its funding and 21 (a third) of its paid staff in 15 months, due to 4 national schemes ending. It will have to downscale its offers at Bilston and Low Hill unless replacement resources for legal aid are found. The WVSC has suffered a similar range of cuts. The Asian womens’ advice agency AWAAZ closed in 2011, and the veteran All Saints local agency (the Haque Centre) closed in 2009/10. Only charitable free food outlets appear to be blossoming in this policy area, which are a genuinely welcome practical phenomenon, but treat the symptoms of need, not the causes.

    e)  Summary of current position and key concerns

    The scale of the welfare reforms, set against an austere economic outlook, as yet unproven prevention services, and rapidly deteriorating traditional sources of assistance, suggest that something in the region of £70million – £120million of year on year combined welfare cuts and economic strains could be felt in theWolverhamptoneconomy up to 2017. Amongst these are some emerging and especially local vulnerability issues:

    • lone parents, usually women, with low skills in larger households, especially with younger children
    • claimants for whom digital benefit applications and onerous conditionality obligations (90 minutes travelling to work) are problematic
    • those who are unaware of or do not access support services and are not flagged as vulnerable
    • those (from many backgrounds) who may become newly mentally unwell under the storm of negative pressures (such as spiralling debts and personal isolation)
    • some younger adults from Black and Mixed Black/White backgrounds already consistently show up as exceptionally vulnerable to personal indebtedness in CAB data
    • it is possible to forecast some families who will be exceptional losers under the changes: a workless lone parent with over 3 children in a heavily mortgaged property on the SVR could face both the worst of welfare cuts and the worst of the economic situation, and find less local support than ever before

    3.0 Way forward

    In a nutshell, it’s all going to happen. The questions are therefore not really about if and when, but exactly what tangible effects will occur in our city. Based on theUSAexperience, current government timetables and unavoidable forecastedUKfactors (like the national economic situation) the following expectations are presumed:

    • the majority of circa 100,000+ affected Wolverhampton claims (from a lesser number of local people) will adequately convert to the new welfare era, some less comfortably than others, although a higher proportion of rent arrears cases will result as landlords seek to reclaim unpaid rent
    • Wolverhamptonwill cope slightly less well than many other areas, due to longstanding local issues (the kinds of issues that have revealed a vulnerability to child poverty)
    • some households will lose over £4000pa via the Benefits Cap, many being lone parents and/or with larger families
    • less will be spent in the local shops and economy
    • from 2013/14 there could well be a rise in repossessions and more households presenting as homeless
    • a large number of extra enquiries will be brought to advice agencies, which will have less capacity to run legal casework
    • stress and mental wellbeing issues will increase to some degree across many groups
    • a hard to quantify rise in destitution and homelessness will occur for some vulnerable groups
    • a few harrowing cases will appear in the media, and increased lobbies will emerge from campaign and faith groups, but overall public support and political agreement for welfare reform remains strong
    • pockets of small-scale protest and anger may occur, for instance bailiffs at work being rebuked by local people
    • modest re-compaction of households, principally young adult people moving “back home”
    • the Local Authority will have greater overall responsibilities but little local control over the private sector prevention service contractors
    • child poverty is likely to creep higher, at least in the medium term, and safeguarding concerns may remain high
    • some increased disrepair as landlords’ income wanes and some mortgaged landlords are themselves repossessed, cascading unwitting tenants into homelessness

    4.0 Recommendations – specific

    1     Assess the total loss of income to the city from all causes until 2017

    2     Estimate where these losses will have an affect (ie by neighbourhood, or retail sector)

    3     Create an overall narrative for planning purposes, a “Wolverhamptonway”, that is broader than currently emerging agency by agency knowledge

    4     Arrange for DWP officers to liaise on the Benefit Cap with LA officers who possess intelligence on neighbourhoods, vulnerability and housing stock/rent levels

    5     Seek defined partnership engagement from the private firms delivering new prevention contracts

    6     Consider a standing reference group for multi-agency practitioner level officers to co-ordinate intelligence flows, including soups kitchens, landlords and advice agencies alongside senior officers

    7     Access research evidence on theUSAchanges and mental wellbeing effects as “behaviour change” is exerted on populations

    8     Scope popular “living on a budget” skills options – repairing your home, cooking for a family – with a view to social media cascading

    9     Consider the new “local social fund” being linked to social prevention systems

    10  Discuss an extended local Mortgage Rescue Scheme facility, unless a national scheme is made available

    11  Identify key Big Society agencies/functions that must be protected

    12  Prepare some evidence-based and effective new schemes to mitigate against vulnerable groups failing to seek advice and support, for example the “advice in maternity pathway” pilot

    Jeremy Vanes

    Comments Off on The impact of national welfare reforms on Wolverhampton, alongside other disruptive factors, 2011-2017

    A public health disaster

    The DWP’s benefit sanctions have become a serious threat to public health – and health professionals should become engaged in exposing their effects and pressing for their abolition.

    Like any insurance scheme, unemployment benefit has always had qualifying conditions. For most of the time up to 1986 there were few disqualifications, except for a ban of up to 6 weeks where people left a job voluntarily or lost it without good reason. But since 1986 there has been a growth of ‘sanctions’ – fines administered by officials to make claimants do particular things which the state, often very disputably, claims are a good idea, such as applying for 30 jobs a fortnight.

    Under the Coalition, JSA and ESA sanctions have almost doubled, to 1.1m per year, affecting about 0.7m people. More than one fifth of all JSA claimants are now sanctioned over any 5-year period. JSA sanctions are running at 7% of claimants per month, and twice this for people aged 18-24; ESA sanctions are rising rapidly and are now close to 1.5% per month. Lone parents on Income Support have also been sanctioned since 2001, though since 2008 they have been moved progressively to JSA where 4% are sanctioned per month.

    All the commonest JSA sanctions have been lengthened since October 2012. The minimum period is now 4 weeks, with 13 weeks for a second ‘failure’. There are now 3-year sanctions for repeat ‘high level’ ‘failures’, which have already hit over 1,000 JSA claimants. Since December 2012, sanctioned ESA claimants have lost all of their personal allowance, instead of the much smaller ‘work related activity’ component.

    Prior to 1988, disqualified claimants were entitled to Supplementary Benefit as of right at a reduced rate, on the normal criteria. Since then (1996 for those on contributory benefit), sanctioned claimants have been eligible only for discretionary ‘hardship payments’. This system, devised by Michael Portillo and Peter Lilley, involves a special, harsh test designed to ensure that the claimant is entirely cleaned out of resources. For instance there is no payment if the claimant has borrowed cash from a payday lender. There is a two-week wait before claimants, however destitute, can even apply, except for arbitrarily defined ‘vulnerable’ groups. Ministers and officials know that this system damages people’s health. As to whether a claimant’s health condition makes them ‘vulnerable’, the DWP’s Decision Maker’s Guide devotes 52 pages to the question:  Will this claimant’s health decline more than a normal person’s would ?  Less than a quarter of sanctioned claimants get hardship payments, and the separate application process and deficiencies in the DWP’s administration mean that they are frequently not paid even to those entitled. Under Universal Credit, hardship payments will become loans, and the rules even stricter.

    Although the money lost through sanctions is greater than in the scale of fines available to the courts, benefit claimants do not have the protections given to offenders. There is no consideration of their circumstances before a sanction is imposed, and no legal representation. Official studies have shown that claimants find the appeal system too difficult to use. In 2013 only 31% asked for reconsideration by the DWP and only 3% appealed to an independent tribunal. Consequently, huge numbers of unreasonable and unlawful sanctions go unchallenged.

    There has never been any specific study of the impact of sanctions on health, but from official studies, reports by voluntary organizations, and claimants’ own stories, there is a large volume of evidence of effects which are known to damage health. Conditions such as depression, irritable bowel syndrome and diabetes are worsened. The death from diabetic ketoacidosis in July of a claimant from Stevenage, David Clapson,  has been reliably attributed to a JSA sanction which meant he couldn’t afford to keep his fridge going. Hunger, cold, damage to family relationships, debt, homelessness, crime (including ‘survival theft’ and violence) and disempowerment are all predictable consequences of the total loss of income, and all have been extensively documented. About a quarter of sanctioned claimants use Food Banks, and a similar proportion of Food Bank users are sanctioned claimants. By contrast, there is no satisfactory evidence that sanctions do more than drive people off benefits, or at best into bad and unsustainable jobs, and even the OECD – long an advocate for sanctions – agrees that to achieve even these limited effects, sanctions do not have to be anything like as harsh as they are in the UK.

    Recently (3/4/2014), the House of Commons agreed a resolution moved by Michael Meacher MP: “this House notes that there have been many cases of sanctions being wrongfully applied to benefit recipients; and calls on the Government to review the targeting, severity and impact of such sanctions.” This added to calls for a comprehensive inquiry from many quarters, in particular the House of Commons Work and Pensions Committee. 

    A limited review (the Oakley review) was earlier conceded by the Coalition and reported on 22 July.  It elicited a great deal of evidence on the working of the sanctions regime, some of which can be found on the Child Poverty Action Group website . However it was given very restricted terms of reference, and although the Coalition says it has accepted all the recommendations, in practice it hasn’t. Consequently, although some useful reforms are taking place, most of the problems in the sanctions system are being left untouched, and the need for a comprehensive independent inquiry remains.

    Fundamental change is required. The UK sanctions regime is incompatible with the UN Principles on Extreme Poverty and Human Rights, which require governments to ensure adequate food and to recognise poor people as free and autonomous agents. As the Scottish Parliament’s Welfare Reform Committee has asserted, the culture needs to change from punitive to supportive. And no one should be made destitute by sanctions or disallowances.

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    The “Due North” report sets out actions that can be taken by organisations and communities in the North and by central government to ‘turn the tide’ on the unacceptable health inequalities that exist within the North and between the North and the rest of England.

    The causes of these health inequalities are broadly similar across the country; differences in poverty, power and resources needed for health. But the severity of the causes is greater in the North.  What is of particular concern is that many of these trends are getting worse, the gap is widening and austerity measures are making the situation even worse, impacting more heavily on the North and disadvantaged areas.

    There are, however, new opportunities. Local government has recently been granted new responsibilities to tackle the causes of poor health and health inequalities and increasingly local governments in the North are demanding greater control of resources previously controlled by Whitehall. It is against this background that the independent Inquiry on Health Equity for the North was set up. The inquiry highlights how northern agencies can make the best use of these devolved powers to do things more effectively and equitably. It also sets out actions that only central government can take to improve health equity.

    What is the Inquiry?

    The Inquiry was commissioned by Public Health England (PHE) and led by an independent Review Panel. The panel brought together leading policy makers, practitioners and academics from local authorities, the NHS, the voluntary sector and universities from across the North of England.  It was chaired by Professor Margaret Whitehead from the University of Liverpool. Recommendations were developed through submitted evidence papers and a series of policy sessions at which discussion papers were presented and policy, practice and public witnesses were invited to give their expert opinions.

    What needs to happen?

    The report sets out a series of evidenced based recommendations for agencies in the North, central government, the NHS and Public Health England.

    Agencies in the North, from communities to organisations and enterprises, working together can make a difference by:

    • Linking up Northern economic development programmes and public service reform to support people into employment – actions focused on the twin aims ofpreventing poverty and promoting prosperity;
    • Deepening collaboration across the North, between Combined Authorities that involve cities, counties and districts across the North to drive a programme of devolution and investment that promotes economic growth and tackles inequalities;
    • Tackling the major causes of health inequalities: poverty, poor housing and unemployment. Working together, agencies in the North can reduce health inequalities by implementing and regulating the Living Wage; reducing child poverty; increasing the availability of high quality affordable housing through stronger regulation of the private rented sector and through new sources of investment in new homes; and by using a joint progressive approach to procurement that promotes health and supports people into work;
    • Maintaining and expanding the provision of universal good quality early years education and childcare and integrated neighbourhood support for early child development with a central role for health visitors and children’s centres;
    • Reducing the democratic divide. The most disadvantaged members of society lack influence on how public resources are used. All levels of local government have a role to play to enhance the democratic engagement of the communities they represent. Citizens should be more involved in shaping how local budgets are used and in influencing local decision-making.

    Central government needs to support action to reduce health inequalities within the North and Between the North and the rest of England by:

    • Ensuring national policies reduce debt and poverty, particularly amongst families with children. This includes setting welfare benefits so they provide a minimum income for healthy living and providing incentives to private sector organisations and legislation for public sector contractors to pay a living wage and end in-work poverty;
    • Making sure austerity measures do not widen inequalities;
    • Developing a fair deal between agencies in the North and national government that allocates the total public resources for local populations so that they reduce inequalities in life chances, within the North and between the North and the rest of England;
    • Leading a national industrial strategy that reduces inequalities between regions by investing in sectors that promote sustainable and quality employment in disadvantaged areas;
    • Prioritising investment in the early years. Including increasing the proportion of overall expenditure allocated to the early years, increasing investment in expanding universal good quality early years education and child care and support to families through children’s centres;
    • Granting local government a greater role in deciding how public resources are used to improve the health and wellbeing of the communities they serve, and greater flexibility to raise funds for investment. This should include control over national budgets for training and programmes to support people into employment;
    • Assessing the impact of changes in national policies on inequalities in health between socioeconomic groups and between regions of the country – and take action on adverse impacts.

    The NHS:

    The NHS needs to build on its considerable achievements in mitigating some of the effects of rising social and economic inequalities.

    • To sustain and increase the impact the NHS has on health inequalities between rich and poor and the North-South Divide, it must:
    • maintain the NHS core principle of equitable access to high quality health care, free at the point of need;
    • integrate locally to develop services that prevent poor health and poverty across the life course (including using its commissioning and procurement power to maximise social value for the North);
    • reaffirm its role as a champion for action on health inequalities by all organisations.

    Public Health England:

    Public Health England was established to be an independent advocate for actions across all sectors on health inequalities.  Public Health England needs to be supporting and challenging local agencies and central government departments to tackle health inequalities.

    “Due North” offers solutions to complex problems from a Northern perspective. We have lived with the North-South health divide for too long, and action is long overdue – the recommendations in the report provide a way forward.

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    In a recent announcement about cutting youth unemployment benefits, Ed Miliband taps into prevailing public opinion by insisting that those on benefits must work to acquire skills in order to deserve them. The way he speaks of those who claim benefits is completely in tune with those who demonise the poor, with sound bites such as ‘Labour… will get young people to sign up for training, not sign on for benefits’.[i]

    This prevailing belief is in stark contrast to two key trends over the last few decades, argues Peter Taylor-Gooby, Professor of Social Policy at the University of Kent in a paper to be published in Policy & Politics. He explains: “The first is that about three-fifths of people below the poverty line live in households where there is at least one full-time earner. Much working-age poverty is a problem of low wages, not of unemployment and ‘spongers’. Secondly, spending in other areas of the welfare state such as health care, pensions and education has grown very much faster than the benefits directed at the poor, unemployment benefit and social housing. Spending on the poor is unimportant as a cause of current public spending problems.”

    In the paper, Taylor-Gooby claims that it is quite clear that Labour’s policy is more influenced by the imperative of winning votes than by considered plans for the welfare state in the long term.

    Instead he argues that a more viable and humane welfare state is possible through policies that help those on low incomes and produce a return for society. Examples he cites include providing training for those without skills, or child care so mothers can work, as well as higher minimum wages to raise incomes at the bottom and reduce the costs of welfare.

    For more information on his response to the welfare crisis, read Taylor-Gooby’s article ‘Making the Case for the Welfare State’ to be published in Policy & Politics or for a press copy contact the Policy & Politics press office on 01179 546721.

    First published on the Policy and Politics blog

    Comments Off on Why is Labour demonising the poor and widening social inequalities?

    These amendments relate to the Stability and Prosperity consultation document.   They are merely ideas at present.  Nobody has agreed them.

    Page 4

    line 8 insert “We want to see a community in which power, wealth and opportunity are in the hands of the many not the few and where the rights we enjoy reflect the duties we owe. This will not happen in an unhealthy society where wealth is primarily inherited and the benefits of economic growth go to those who are already rich.  Reducing economic inequality will be a central concern of the Labour Government”

    Page 5

    Insert  at line 44 after ‘future success.’ “Key to building an economy which creates sustainable economic growth in every region of the country will be supporting micro, small and medium sized businesses. A growing sector that has the potential to increase employment opportunities at the same time as demonstrating that there is a more ethical model of doing business is the social enterprise, co-operative and not-for-profit economy. These models have also proved themselves to be remarkably effective and resilient.”

    Page  7

    Insert at  line 45: “Widening access to the UK Payments system to allow a greater number of financial services providers – including credit unions – to provide current accounts will increase competition in the market and offer a better deal for consumers.”

    Page 8

    Line 17 insert:  “As the major banks have closed branches on our high streets the payday lenders have moved in. More than 1 million people take out payday loans every year totalling almost £2bn. One Nation Labour will cap the overall cost of credit to prevent these high cost lenders from charging the most exorbitant rates. We will also introduce a new levy on payday lenders and use the resources to support the expansion of credit unions. With the right support credit unions can play a growing role in the provision of financial services – as they do in other developed countries including in Ireland and Canada. Key to supporting this growth would be increasing the number of employers who offer payroll deduction of savings and loan repayments. A Labour Government will look to public sector employers to lead the way.”

    Line 31 insert “We will use a new tax on wealth to finance the NHS and social care system”

    Page 10

    Line 22 insert “We will rebalance the social security system to offer more support to pregnant women, parents and children in the early years.”

     

    2 Comments

    These amendments relate to the Living Standards and Sustainability consultation document.   They are merely ideas at present.  Nobody has agreed them.

    Page 3

    Line 42 Delete “includes” insert “prioritises”

    Insert new heading “Transport and health ”

    Insert “Traffic accidents are higher in more disadvantaged and urban areas (particularly amongst children and outside schools) – perhaps due to the higher volume of traffic in such areas, and are the leading cause of death in children over 5. There is a strong evidence base that shows that reducing traffic speeds from 30mph to 20mph results in a reduction in accidents.  We will encourage widespread introduction of 20 mph limits in urban areas to encourage the reclaiming of our streets by pedestrians.

    The Active Travel (Wales) Act 2013 will be extended to England.  Every local authority will be required to publish details of expenditure on transport measures divided between walking, cycling, public transport and motor vehicles.   We will rebalance the transport budget so that 10% is spent consistently over the length of the parliament on the needs of pedestrians and cyclists with the aim of building networks of segregated cycle tracks in every major city.  We will remove VAT from bicycles.

    We will take urgent steps to reduce the air pollution caused by road traffic, and in particular by diesel engines. We will reconsider the taxation of vehicles and motor fuel in the light of the evidence of damage to health caused by particulates.

    We will reduce the level of alcohol which is permitted for motorists”

    Page 4

    Line 15 add “Free bus passes should be extended to  unemployed and workless people to enhance employability and job search. New ways of enhancing mobility for disadvantaged people and developing community transport, especially in rural areas, will be explored. ”

    Page 6

    Line 30 Delete “Encouraging safer cycling” and following 2 paragraphs.

    Page 10

    Line 35 insert “Central government should provide funds to local authorities to ensure that public transport is continued to be made available in rural areas to connect communities with services.”

    Line 50
    “The decline in rural services has been well documented. Rural co-operatives, such as community-owned shops, post-offices and pubs, and other social enterprises can be the only viable alternative for communities looking to retain or re-introduce a service in areas of market failure. However, it is still a real challenge for communities to mobilise quickly enough when a local service is under threat and the current rules mean that communities will find a wide range of barriers, including legislative, planning and financial barriers, when wanting to save vital services. One Nation Labour will change the balance of power so that communities have the ‘right to try’ to put together a community run model which can keep services open.”

    Page 11

    Line 19 delete “Issues around public health and diet are addressed in the Health and Care Final Year Policy Consultation”.  Insert “Healthy food is not an issue for the NHS, except that the NHS bears the costs arising from the consumption of unhealthy food.  It is the responsibility of the government to protect the health of the population and to defend it from those who make a profit from selling unhealthy food and drink whether the damage is immediately apparent or more insidious.  We will remove the VAT exemption from sugar, which has no nutritional value.  We will ensure that the quantity of sugar, salt and fat in manufactured food is easily apparent to customers wherever it is sold. We will ban the use of trans fats in food products (as has been done in Denmark) – and push for the ban to be extended throughout the EU.”

     

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    This is  based on a press release from the revolutionary socialists of the Organisation for Economic Co-operation and Development

    The shares of the richest 1% in total pre-tax income have increased in most OECD countries over the past three decades. This rise is the result of the top 1% capturing a disproportionate share of overall income growth over that timeframe: up to 37% in Canada and 47% in the United States, according to new OECD analysis.

    Shares of top 1% incomes in total pre-tax income, 1981-2012

    Shares of top 1% incomes in total pre-tax income, 1981-2012 (or closest)

    Even in countries which have a history of a more equal income distribution, such as Finland, Norway and Sweden, the share of the top 1% increased by 70%, reaching around 7-8%. By contrast, top earners saw their share grow much less in some of the continental European countries, including France, the Netherlands and Spain.

    Share of income growth going to income groups from 1975 to 2007

    Share of income growth going to income groups from 1975 to 2007

    But the incomes of the poorest households have not kept pace with overall income growth, with many no better off than they were in the mid-1980s. Stripping out the richest 1 percent of the population leaves income growth rates considerably lower in many countries – which is why so many people have not felt their incomes rising in line with overall economic growth.

    The crisis put a temporary halt to these trends – but it did not undo the previous surge in top incomes. On average, real incomes of the top 1% increased by 4% in 2010, while the lower 90% of the population saw their real incomes stagnate.

    Percentage changes in real incomes across income groups, average of nine OECD countries, 2008 to 2010

    Percentage changes in real incomes across income groups, average of nine OECD countries, 2008 to 2010

    Tax reforms in almost all OECD countries over the past 30 years have substantially cut top personal income tax rates, the average rate in OECD falling from 66% in 1981 to 43% in 2013. This reduction  has been closely associated with rising top income shares. Other taxes which play a role for top incomes were also lowered: the average statutory corporate income tax rate declined from 47% to 25% and taxes on dividend income for distributions of domestic source profits fell from 75% to 42%.

    Top statutory personal income tax rates in the OECD area, maximum, minimum and average, 1981 to 2013

    Top statutory personal income tax rates in the OECD area, maximum, minimum and average, 1981 to 2013

    “Without concerted policy action, the gap between the rich and poor is likely to grow even wider in the years ahead,” said OECD Secretary-General Angel Gurría. “Therefore, it is all the more important to ensure that top earners contribute their fair share of taxes”.

    The paper outlines a series of reforms governments could make to help ensure that top earners contribute their fair share of the tax burden. These include:

    • Abolishing or scaling back a wide range of those tax deductions, credits and exemptions which benefit high income recipients disproportionately;
    •  Taxing as ordinary income all remuneration, including fringe benefits, carried interest arrangements, and stock options;
    • Considering shifting the tax mix towards a greater reliance on recurrent taxes on immovable property;
    • Reviewing other forms of wealth taxes such as inheritance taxes;
    • Examining ways to harmonise capital and labour income taxation;
    • Increasing transparency and international cooperation on tax rules to minimise “treaty shopping” (when high-income individuals and companies structure their finances to take account of favourable tax provisions in different countries) and tax optimisation;
    • Broadening the tax base of the income tax, so as to reduce avoidance opportunities and thereby the elasticity of taxable income;
    • Developing policies to improve transparency and tax compliance, including continued support of the international efforts, led by the OECD, to ensure the automatic exchange of information between tax authorities.

    In many OECD countries, the rise in overall inequality has also been driven by low-income households falling behind in relative and, sometimes, in real terms. In order to tackle the increase of overall inequality, a comprehensive policy strategy for promoting opportunities for those at the lower end of the distribution is needed. Beyond tax reforms, such a package includes transfer policies and other social policies, as well as labour market and education policies.

    The paper “Focus on Top Incomes and Taxation in OECD Countries: Was the crisis a game changer?”, all figures and data, a short video and more information on OECD work on inequality are available on the OECD website

    1 Comment

    In this article, I argue that paying the Living Wage should be a public health priority for all publicly funded bodies.

    The living wage is a carefully calculated wage designed to provide employees with a minimum standard of living.  Currently it is set at £7.65 per hour (£8.80 in London), compared to the minimum wage of £6.31 per hour.  Currently some 4.8 million people, 20% of the working population, work for less than the living wage.

    We know that the living wage is good for employers, reducing absenteeism by 25%, and turnover of contractors falling from 4% to 1%. It is also eminently realistic and achievable, indeed over 100 Local Authorities have a living wage policy already. What is less discussed, however, are the large public health benefits of the living wage.

    The public health argument in support of the Living Wage is clear. Professor Kate Pickett calls it “the single best action that I believe local authorities can take to reduce health inequalities”. This is because it will reduce poverty and income inequality and these are very important factors that determine the health and wellbeing of our communities.

    Firstly the living wage will reduce poverty. Poverty exposes people to health threats such as poor housing and low quality food. Poverty also causes psychological and social stress, which results in poorer mental and physical wellbeing. Indeed, workers on the living wage report higher levels of mental wellbeing than those below the living wage. Finally, poverty makes it practically and psychologically more difficult to adopt healthy behaviours, resulting in people smoking more, eating less healthily and doing less exercise. Through these mechanisms poverty causes the UK’s shocking levels of health inequalities. For instance women in Tower Hamlets where I work can expect to be healthy for 54.1 years, whereas women in Richmond can expect to be healthy for 72.1 years.

    Secondly, the living wage will reduce income inequality. Income inequality is one of the most toxic social determinants of health. Income inequality harms people on low incomes because it intensifies their feeling of low social status. Biologists and epidemiologists have shown how this results in high levels of stress, which increases cardiovascular disease and mental illness.

    Most interesting of all, income inequality harms not only the health of those on low incomes, but also the health of the whole population, including the rich. Studies again and again confirm that countries that are more equal are healthier. This is partly because there is less social stress in equal societies but also because equal societies make a whole series of better collective decisions. Being healthy requires collective decisions on provision of healthcare, on acceptable levels of air pollution, on provision of green parks and good cycle lanes. People can only be healthy if we all decided to be healthy together, and that only happens in equal societies. By moving towards a more equal society research has shown that we can expect health gains from lower cardiovascular disease, obesity, drug dependency, mental illness, suicides and homicides, childhood wellbeing and infant mortality.

    In summary, public bodies paying the living wage will not solve health inequalities. However it is a simple and achievable step towards equality. There will be large health benefits through reducing poverty and income inequality, enabling people to live healthier, less stressful lives, and enabling us all to make healthier collective decisions.

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    We are all shamed by Scotland’s poor health record, but we are even more shamed by the wide socioeconomic inequalities in health. Inequalities that see the poorest, most disadvantaged bearing the greatest burden and suffering the most. Health inequalities are the unjust differences in life expectancy (how long we live) that are observed across our communities, cities, and country – differences determined by socioeconomic position or circumstances, determined by the unfair distribution of income, wealth, and power. In the Socialist Health Association Scotland, we believe we must tackle health inequalities that play out in health and disease, in life and death is the greatest challenge we face as a society.

    The time for action on health inequalities is now. And we are delighted to announce that Neil Findlay MSP, Shadow Cabinet Secretary for Health and Wellbeing and the Scottish Labour Party have grasped this thistle and have commissioned the health inequalities policy review.

    Our launch meeting, in the Scottish Parliament in February 2014, brought together a diverse “Reference Group” with representatives from community groups, activists, the voluntary sector, councils, health professionals, academia, Unions, the Labour Party, and the Socialist Health Association, and included a priority setting workshop.

    The Reference Group agreed an overarching vision of the commission – to make tackling health inequalities a top priority and to propose a suite of policies for action. The Commission will have the following aims:

    1. To understand the scale and depth of health inequalities; thoroughly clarifying both the manifestations of health inequalities and the social, political and economic determinants of health inequalities.
    2. Across health and other public services to examine ways to tackle the Inverse Care Law and ensure resources are allocated proportionate to need.
    3. To consider short, medium and long term policies needed to tackle health inequalities (incognisance of current and potential future constitutional arrangements).
    4. To propose and cost specific policies that would help tackle health inequalities. This should take into account current spending realities, but could also consider what could/should be done with reallocating and reprioritising resources or under a financial situation that is different that differs from the current arrangement; this should look at both more generous settlements than those in place presently.
    5. To consider how and where cross-portfolio work could/should take place to tackle health inequalities.

    We are planning to undertake a process of community engagement in the policy development process.

    We have set a call for written evidence on the following questions:

    • What is the character of health inequalities? What do they mean for communities and families?
    • What role can health and other public services play in tackling health inequalities?
    • Are there any specific policies, initiatives or research evidence from Scotland, UK or internationally that you would propose to tackle health inequalities?

    Other specific questions:

    • What can be done within current devolved arrangements to tackle health inequalities?
    • What further devolving of powers would enable health inequalities to be tackled?
    • What mechanisms can be deployed to better join up policy and public services to tackle health inequalities?
    • What can be done to tackle the Inverse Care Law in health and other public services?
    • Is democratisation of health services important in tackling health inequalities?
    • How would community development efforts be better supported to tackle health inequalities?
    • How could resource allocation (geographic and in other budget planning terms) to health and public services be re-allocated to tackle health inequalities?

    To respond to this call, please submit written evidence email tommy.kane@scottish.parliament.uk by end of May 2014.

    This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014

    Dr David Conway is  Chair of Scottish Labour’s Health Inequalities Commission

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